The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder

304 Pages·2007·1.36 MB·English

by  Allan V. Horwitz

The Loss of Sadness
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The Loss of Sadness
How Psychiatry Transformed Normal Sorrow
Into Depressive Disorder
Allan V. Horwitz and Jerome C. Wakefi eld

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Copyright © 2007 by Allan V. Horwitz and Jerome C. Wakefi eld
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Library of Congress Cataloging-in-Publication Data
Horwitz, Allan V.
The loss of sadness : how psychiatry transformed normal sorrow into depressive disorder / Allan V.
Horwitz and Jerome C. Wakefi eld.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-19-531304-8
1. Psychiatry Miscellanea. 2. Depression, Mental Miscellanea. 3. Mental illness Miscellanea.
I. Wakefi eld, Jerome C. II. Title.
[DNLM: 1. Diagnostic and statistical manual of mental disorders. 2. Depression. 3. Depressive Disorder.
WM 171 H824L 2007]
RC480.5.H667 2007
616.89 dc22 2006032581
9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
To David Mechanic
—AVH
To my parents, Helen and Ted Sherman
—JCW
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Foreword
T
he book you are about to read is a brilliant tour de force of scholar-
ship and analysis from two of our leading thinkers about psychi-
atric diagnosis and the nature of mental disorders. Allan Horwitz and Jerome
Wakefi eld’s T he Loss of Sadness represents the most cogent and compelling “in-
side” challenge to date to the diagnostic revolution that began almost 30 years
ago in the fi eld of psychiatry. The authors begin by arguing for the existence of
a universal intuitive understanding that to be human means to naturally react
with feelings of sadness to negative events in one’s life. In contrast, when the
symptoms of sadness (e.g., sad feelings, diffi culty sleeping, inability to concen-
trate, reduced appetite) have no apparent cause or are grossly disproportionate
to the apparent cause, the intuitive understanding is that something important
in human functioning has gone wrong, indicating the presence of a depressive
disorder. Horwitz and Wakefi eld then persuasively argue, as the book’s central
thesis, that contemporary psychiatry confuses normal sadness with depressive
mental disorder because it ignores the relationship of symptoms to the context
in which they emerge. The psychiatric diagnosis of Major Depression is based
on the assumption that symptoms alone can indicate that there is a disorder;
this assumption allows normal responses to stressors to be mischaracterized as
symptoms of disorder. The authors demonstrate that this confusion has impor-
tant implications not only for psychiatry and its patients but also for society in
general.
T he book’s thesis is of special interest to me, because I was the head of
the American Psychiatric Association’s task force that in 1980 created the
DSM-III (i.e., the third edition of the D iagnostic and Statistical Manual of Mental
Disorders, the Association’s offi cial listing of recognized mental disorders and
the criteria by which they are diagnosed). This was the fi rst edition of the M anual
to off er explicit symptomatic criteria for the diagnosis of each mental disorder.
Now in its fourth edition, the DSM is generally considered to have r evolutionized
viii FOREWORD
the psychiatric profession. It serves to defi ne how researchers collect their
s amples, what conditions insurance companies will reimburse, what conditions
courts and social agencies treat as illnesses, and how individuals themselves in-
terpret their emotional experiences. The DSM ’s standardization of psychiatric
diagnosis by using explicit rules for making a diagnosis has been critical to the
explosion of research and knowledge in the mental health fi eld. It has allowed
clinicians and researchers with diff erent theoretical perspectives, and thus dif-
ferent languages, to communicate with each other. It has also addressed doubts
about psychiatry’s scientifi c status, such as concerns about the reliability of its
diagnoses.
Yet the very success of the D SM and its descriptive criteria at a practical level
has allowed the fi eld of psychiatry to ignore some basic conceptual issues that
have been lurking at the foundation of the D SM enterprise, especially the ques-
tion of how to distinguish disorder from normal suff ering. This book will bring
increased attention to these conceptual problems.
My involvement in an earlier debate over whether to remove homosexuality
from D SM-II in 1973 led me to grapple with the question of how to defi ne men-
tal disorder. I formulated the defi nitions of mental disorder in the introductions
to the D SM-III, the DSM-III-R (the DSM’s third edition revised), and the DSM-IV,
which aim to explain the reasons that certain conditions were included in and
other types of problems excluded from the Manual. Since then, Dr. Wakefi eld
has critiqued my eff orts in ways that I have largely become convinced are valid.
His evolution-based “harmful dysfunction” analysis of the concept of mental
disorder raises subtle, nuanced questions about mental disorder that challenge
one’s thinking, no matter where one falls on the issues. It is easily the most
widely cited and provocative analysis of the concept of mental disorder that ex-
ists today, simultaneously defending the concept as legitimate and providing a
framework for this book’s critique of current diagnostic standards as too broad.
Moreover, Horwitz and Wakefi eld point out that the DSM is not consistent even
in applying its own defi nition of mental disorder to the diagnostic criteria sets
for specifi c disorders. Whereas the DSM defi nition of mental disorder, like the
harmful-dysfunction approach, clearly specifi es that a disorder involves a dys-
function in the individual and is not an expectable response to a stressor, the
formulation of the DSM’ s diagnostic criteria sets rarely took this into account.
In other words, its criteria specifi ed the symptoms that must be present to justify
a given diagnosis but ignored any reference to the context in which they devel-
oped. In so doing, they allowed normal responses to stressors to be characterized
as symptoms of disorder.
Many critiques of the DSM have come from the “outside” in that they have
been suspicious of the very notion of a mental disorder and thus rejected the
idea of a psychiatric diagnostic manual as inappropriately medicalizing social
problems. In contrast, Horwitz and Wakefi eld recognize the D SM ’s contributions
FOREWORD ix
and accept its assumption that there are genuine mental disorders in the strict
medical sense. Ironically, it is by taking seriously the D SM ’s claim to be a manual
of mental disorders (and thus to fall within the scope of medicine) that the au-
thors are able to mount a devastating critique of the way the DSM operational-
izes the diagnosis of depression (and by implication, other diagnostic categories
as well) with inadequate attention to context. Because their analysis is anchored
in psychiatry’s own assumptions, it will be hard for those now constructing the
DSM-V (expected publication in 2011) to ignore.
Horwitz and Wakefi eld trace the history of the diagnosis of depression, be-
ginning with Hippocrates and working through to the present, and show with
impressive and persuasive scholarship just how consistently their view—rather
than the DSM ’s approach in which symptoms alone can indicate disorder—is
refl ected in the historical traditions of medicine and psychiatry, even including
the work of Emil Kraepelin, the psychiatrist often considered the inspiration for
the DSM-III. It should be noted that at the time the diagnostic criteria for de-
pression were originally developed, they were intended for research samples in
which it was a reasonable assumption that the patients were disordered. The
authors argue that, when those same diagnostic criteria that contain no refer-
ence to context are used in community epidemiological studies and screening of
the general population, large numbers of people who are having normal human
responses to various stressors are mistakenly diagnosed as disordered. The re-
searchers who have conducted the major epidemiological studies over the past
two decades have totally ignored this problem. The result has been semioffi cial
prevalence rates that many fi nd unbelievable.
The authors’ analysis of disorder itself does not state exactly where the line
between dysfunction and normality is to be drawn and allows that the boundary
is fuzzy. I have to admit that I would be inclined to draw the boundary so as to
include more under “disorder” than they do. Frankly, I remain cautious about
the possibility of incorporating context into diagnostic criteria and about the
unreliability and false negatives that might result. But it has yet to be tried in a
serious way. This book will place this issue on psychiatry’s agenda and make it
one of the major topics that should be considered in the upcoming revisions that
will yield the D SM-V. However the problem is resolved, because of this book the
question will have to be posed; it can no longer be ignored.
Relentless in its logic, Horwitz and Wakefi eld’s book forces one to confront
basic issues that cut to the heart of psychiatry. It has caused me to rethink my
own position and to consider how the authors’ concerns might best be handled.
It will shape future discussion and research on depression, and it will be an in-
dispensable guide to those who are rethinking psychiatric diagnostic criteria in
preparation for the DSM-V. It would be interesting to look back 100 years from
now and see whether context is as crucial to diagnostic criteria as the authors
believe it to be or whether the stricter symptom-based approach can somehow